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5-2001

Attitudes and Behaviors of Adolescents toward

Sunbathing and Sunscreen Use.
Billie Hill Murray
East Tennessee State University

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Murray, Billie Hill, "Attitudes and Behaviors of Adolescents toward Sunbathing and Sunscreen Use." (2001). Electronic Theses and
Dissertations. Paper 136. http://dc.etsu.edu/etd/136

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 Attitudes and Behaviors of Adolescents Toward Sunbathing and Sunscreen Use

A Thesis

Presented to

the Faculty of the Department of Psychology

East Tennessee State University

In Partial Fulfillment

of the Requirements for the Degree

Master of Arts in Clinical Psychology

by

Billie Hill Murray

May 2001

Joel Hillhouse, Chair

David Marx
James S. Perry

Keywords: Sunbathing, Suntanning, Sunscreen, Adolescents, Alternative Behaviors, Tanning

 ABSTRACT

ATTITUDES AND BEHAVIORS OF ADOLESCENTS TOWARD SUNBATHING AND

SUNSCREEN USE

by

Billie H. Murray

This study explored the attitudes and behaviors of adolescents toward sunbathing and sunscreen use
by employing the Theory of Alternative Behaviors (Jaccard, 1981) with adolescent participants and a
respective parent co-participant.

Females were found to be more likely to engage in intentional suntanning efforts, to stay in the sun
for a longer duration, and to be more likely to use sunscreen yet to report higher incidence of
sunburns. Those with a healthy lifestyle attitude are as likely to engage in intentional tanning,
although they are more likely to wear sunscreen. Self-report of tanning behavior was positively
correlated to parents observation of adolescents behavior.

Results of this study support the position that sunscreen partially allows for longer sunlight exposure
resulting in higher amounts of UV radiation exposure. Participants who were more likely to wear
sunscreen were likewise more likely to spend more time in the sun and to sunburn more frequently.

2
 CONTENTS

Page

ABSTRACT ....................................................................................................................................... 2
LIST OF TABLES ............................................................................................................................... 6

Chapter
1. INTRODUCTION ..................................................................................................................... 7
UV Radiation as a Risk Factor................................................................................................ 8
Other Risk Factors for Skin Cancer....................................................................................... 11
Sunscreen. .................................................................................................................................. 12
Adolescent Sunscreen Use................................................................................................ 12
Sunscreen Use Among College Students. ...................................................................... 14
Sunscreen Use in the General Population...................................................................... 14
Motives for Tanning................................................................................................................. . 15
Peer and Parental Influence .................................................................................................... 16
On Sunbathing and Sunscreen Use................................................................................. 18
Sunburn...................................................................................................................................... 19
Prevention.................................................................................................................................. 21
Theories of Health Behavior................................................................................................... 24
The Health Belief Model (HBM)..................................................................................... 25
The Health Belief Model in Related Studies.................................................................. 25
Pre-Adult Decision-making Model (PAHDM) ............................................................. 27
Behavioral Alternative Model .......................................................................................... 29
Behavioral Alternative Model in Related Studies.......................................................... 31
Statement of the Problem ....................................................................................................... 33

3
2. METHODS .................................................................................................................................. 35
Subjects ...................................................................................................................................... 35
Measures .................................................................................................................................... 36
Parent/Student Questionnaire......................................................................................... 36
Demographic Variables.............................................................................................. 36
Recent and Previous Sunburn History..................................................................... 37
Sunscreen Use.............................................................................................................. 37
Efficacy of Sunscreen................................................................................................. 37
Skin Sensitivity............................................................................................................. 38
Knowledge and Beliefs about Skin Cancer ............................................................. 38
Family History ............................................................................................................. 38
Social Influence ........................................................................................................... 38
Appearance Motivation.............................................................................................. 39
Health Motivation....................................................................................................... 39
Alternative Behavioral Choices................................................................................. 39
Procedure................................................................................................................................... 40
3. RESULTS ...................................................................................................................................... 41
Demographics .......................................................................................................................... 41
Examination of Gender & Skin Type Differences.............................................................. 42
Examination of Sunburn History & Sunscreen Use ........................................................... 43
Behavioral Alternative Model Evaluation............................................................................. 45
Tanning Attitudes ..................................................................................................................... 48
4. DISCUSSION ............................................................................................................................... 49
Parent/Child Agreement ........................................................................................................ 49
Behavioral Alternatives............................................................................................................ 50
Sunburn History & Sunscreen Use/Attitudes...................................................................... 51
Tanning Attitudes ..................................................................................................................... 53
4
 Gender Differences.................................................................................................................. 54
Procedural Limitations............................................................................................................. 56
Future Research ........................................................................................................................ 57
REFERENCES...................................................................................................................................... 58
APPENDICES....................................................................................................................................... 66
Appendix A: Parent/Child Agreement ................................................................................ 67
Appendix B: Behavioral Alternative Choices ....................................................................... 70
Appendix C: Opinions About Tans, Lifestyles, Sunbathing, Sunscreen and
Risk ................................................................................................................................... 73
Appendix D: Family History, Sunscreen Habits, Sunburn History and
Demographics .................................................................................................................. 76
VITA.. ............................................................................................................................... 79

5
 LIST OF TABLES

Table Page

1. PEARSON BIVARIATE CORRELATION FOR PARENT/CHILD RESPONSES 43

2.RESULTS OF REGRESSION ANALYSIS TESTING OF SUNSCREEN
ATTITUDES......................................................................................................................... 45
3. RESULTS OF REGRESSION ANALYSIS TESTING OF THE THEORY
OF ALTERNATE BEHAVIOR AS TIMES OUTDOORS TO TAN .................. 46
4. RESULTS OF REGRESSION ANALYSIS TESTING OF THE THEORY
OF ALTERNATE BEHAVIOR AS HOURS OUTDOORS .................................. 47
5. RESULTS OF REGRESSION ANALYSIS TESTING OF SUNTANNING
ATTITUDES .......................................................................................................................... 48

6
 CHAPTER 1
INTRODUCTION

According to a publication of the National Cancer Institute (NCI) of the National Institutes
of Health, an estimated 40 to 50 % of Americans who live to age 65 will have skin cancer at least
once (NCI, 1995). When skin cancer occurs, the orderly growth, division, and repair of healthy skin
tissue is altered. At this time, the cells lose their ability to limit and direct normal growth, resulting
in an accelerated, chaotic growth pattern that produces excess tissue in the form of tumors (NCI,
1995). Such malignant tumors are capable of invading and destroying nearby tissue. If left
untreated, cells break away from the tumor and travel through the blood stream or the lymph system
spreading the malignancy to other organs of the body.
Numerous types of skin cancer exist, with the most common types being basal cell,

squamous cell, and malignant melanoma (American Cancer Society [ACS], 1997). Basal cell and

squamous cell are known as non-melanoma because they come from skin cells other than

melanocytes. Approximately one million cases of non-melanoma skin cancer are diagnosed each

year. When diagnosed at an early stage, nearly all non-melanoma skin cancers can be cured. As a

general rule, 95% are cured. Even so, the ACS has predicted that non-melanoma skin cancer would

take the lives of 1,900 individuals in the year 2000 (ACS, 2000).

Basal cell cancer comprises 75% of all skin cancers and forms in the lowest layer of the

epidermis, the basal layer. Areas such as the head and neck are more vulnerable to basal cell

carcinoma because of their increased sun exposure. Once an individual is diagnosed with this slow

growing cancer, a second skin cancer is likely to develop within five years (ACS, 2000).

Squamous cell cancers develop in higher levels of the epidermis and comprise about 20% of

all skin cancers. This form of skin cancer is more aggressive than basal cell cancer and invades

7
tissues beneath the skin. Although squamous cell cancer is more prone to spread than is basal cell

carcinoma, less than one percent spread to lymph nodes and/or other organs (ACS, 2000).

Malignant melanoma begins in the melanocytes, which produce the skin pigment (coloring)

known as melanin. Melanoma tumors are often brown or black because malignant melanoma cells

retain their ability to produce melanin. Comprising only 4% of all skin cancers, melanoma is the

most dangerous, resulting in 79% of deaths from skin cancer (ACS, 2000). No other form of cancer

is increasing as fast, with incidence of melanoma rising at a rate of 4% every year. In the United

States, one person dies per hour from malignant melanoma (American Academy of Dermatology

[AAD], 1996). By the year 2000, the lifetime risk for Americans developing malignant melanoma

was expected to be one in 74 (AAD, 2000) and for 2001 that risk is estimated to rise to one in 71

(AAD, 2001). Such an upsurge in incidence provokes research into the reasons for the rise in cases

of skin cancer, as well as interventions to decrease the occurrence of skin cancer.

UV Radiation as a Risk Factor

Repeated exposure to sunlight has been determined to be the most important risk

factor for skin cancer (ACS, 1997). A strong association exists between skin cancer and

overexposure to ultraviolet (UV) radiation, which comprises only three percent of the total solar rays

reaching the earth (ACS, 1997). UV radiation is subdivided into three groups: 1) UVC rays-

considered the most carcinogenic and is absorbed almost completely by our ozone layer of

atmosphere; 2) UVB rays-responsible for most sunburns and is also known as a carcinogen; 3) UVA

rays-can penetrate the skin to cause damage to the underlying tissue and act synergistically with UVB

radiation to cause skin cancer.

8
 In response to UVA and UVB exposure, existing melanocytes (skin pigment) move closer to

the skin surface as new melanocytes are produced. A byproduct of this effort is the suntan. Tanning

appears to be an adaptive process in which the skin thickens to protect the body from UVA and

UVB exposure. The second layer of epidermis (stratum corneum) also thickens in an effort to

decrease further UVB exposure. The protective factor provided by this process is evident, in that

specimens from tanned skin filter sunburn rays about twice as efficiently as specimens from

untanned skin (Kaidbey & Kligman, 1978). Although the tanning process seems to provide some

defense against sunburn (DeGruijl, Van Der Meer, and Van Der Leun, 1983), this protection is not

achieved without damage to the skin. The eventual cost of tanning far outweighs the minimal

benefit (Bargoil & Erdman, 1993). Therefore, the cumulative effect of suntanning over a lifetime

damages the skin.

Although most skin cancers do not appear until an individual is over 50 years of age, the

damage which caused the cancer probably occurred at an early age. English et al. (1998) conducted

a case-control study of 132 individuals with confirmed squamous cell carcinoma (SCC) and reported

that sun exposure, especially during childhood and adolescence increases the risk of incidence of this

form of skin cancer. Researchers have evidence that non-melanoma cancer is related to cumulative,

daily exposure to the UV radiation over the lifetime of an individual (De Gruiil, Van Der Meer, and

Van Der Leun, 1983; Fears, Scotto, and Schneiderman, 1977).

In contrast to non-melanoma skin cancer, the risk of malignant melanoma appears to be

related to annual UV exposure (Fears, Scotto, and Schneiderman, 1977). Malignant melanoma

appears to be related to brief exposure to high intensity UV radiation. Such episodic bouts of acute

exposure resulting in severe, blistering sunburns place individuals more at risk for malignant

9
melanoma in adulthood (ACS, 1996; AAD, 2000; Green, Siskind, Bain, & Alexander, 1985; Hill,

White, Marks, Theobald, Borland, & Roy, 1992).

According to research, the effects of UV radiation are not typically manifested for 20 years or

more (Bargoil, & Erdman, 1993; Vitaliano & Urbach, 1980; Weinstock et. al,1989). Given this delay,

attention has been directed toward childhood sun exposure. Weinstock et al. has estimated that

individuals receive more than 50% of their lifetime dose of ultraviolet radiation as children and

adolescents. Furthermore, a significant association between blistering sunburns suffered between the

ages of 15 and 20 and the risk of melanoma was found, whereas no significant association was made

between melanoma and sunburns after the age of 30. For development of melanoma, the teenage

years may be the most important time period (Weinstock et al., 1989). Sunburn indicates that a high

level of UV exposure has occurred within the layer of the melanocyte. Those individuals who

experience repeated sunburns are more at risk for melanoma. As few as six sunburns in a lifetime

may double the average risk for melanoma (Green et al., 1985). These findings suggest that efforts

to modify the sunbathing behaviors of children and adolescents should be encouraged because

sunbathing at this age is a potentially hazardous behavior.

A retrospective study by Holman & Armstrong (1984) provides evidence that sun exposure

in early life could be a risk factor for the development of melanoma in later life. Using a unique

sample of migrants to Australia, researchers found that migrants arriving prior to the age of 10 had a

skin cancer incidence rate which was similar to that of native born Australians. While among those

arriving at the age of 10 to 15 exhibited a significant drop in the odds for incidence of melanoma.

For those migrants who had arrived after age 15, the estimated skin cancer incidence rate was one-

fourth the rate for native-born Australians. These results suggest that exposure before the age of ten

may be crucial in the formation of malignant melanoma in later life.

10
 Damage from sun exposure during the early years of life could be eliminated with preventative

behavior in the form of protection from the sun. Regular and appropriate use of sunscreen during

these early years could provide that protection. A study by Stern, Weinstein, and Baker (1986)

suggests that regular (daily) use of sunscreen with a sun protection factor of 15 during the first 18

years of life would potentially reduce the incidence of basal and squamous cell tumors by 78%.

Although this study was particular only to basal and squamous cell, the ACS (2000) recommends

daily use of sunscreen as a preventative measure against melanoma as well.

Other Risk Factors for Skin Cancer

Another significant risk factor is the ability to tan. Those least able to tan are at highest risk

for basal cell carcinoma, (Vitaliano & Urbach, 1980) as well as for squamous cell carcinoma (Marks,

1996). In general, non-melanoma skin cancer is more likely to occur in individuals with fair skin,

especially those who freckle easily. This is because these fair individuals are not protected with an

abundance of skin pigment. Other risk factors for non-melanoma skin cancer include a natural hair

color of blonde or red, and light colored eyes. Both of these features usually occur along with fair

skin (ACS, 1997).

Males are also at greater risk, being twice as likely as women to be diagnosed with

basal cell carcinoma, and three times more likely to have squamous cell cancer (ACS, 2000).

This is thought to be related to outdoor occupational exposure. Chemical and/or radiation

exposure also increases the risk, as does medication used in the treatment of psoriasis. Skin

damaged by inflammatory skin disease or severe burns may be more likely to develop skin cancer.

Individuals with a weakened immune system may also be more at risk. Finally, there are also

inherited or congenital conditions that seem to predispose one to skin cancer.

11
 However, despite all of these risk factors, skin cancer is generally preventable. Even in the

absence of the other risk factors, prolonged and/or intermittent overexposure to the sun puts one at

risk for skin cancer. Thus, even though skin cancer is the most common form of cancer, it is also

the most preventable (ACS, 2000).

Sunscreen

Sunscreen is marketed by a number of manufacturers with various strengths of sun

protection factor (SPF). In addition to the regular formulas, sunscreen is available in waterproof and

bug proof formulas. Sunscreen is available in colors to make it more attractive and encourage its use

by adolescents and children. Even so, the continual increase in incidence of skin cancer suggests

that many individuals fail to effectively use sunscreen as a means of protection against skin cancer.

Adolescent Sunscreen Use

A number of studies have examined sunscreen use in adolescents. Banks, Silverman,

Schwartz and Tunnessen (1992) found less than one tenth of the adolescents they surveyed reported

always using sunscreen, while 1/3 of the sample said they never used such protection. Reynolds et.

al (1996) examined a large group of sixth graders finding that over 1/6 denied ever using sunscreen;

17 % reported using sunscreen three quarters of the time, 1/6 more said they used sunscreen only

half of the time, while over 40% said their use of sunscreen was limited to one in four exposures to

the sun. This study also found a strong association between sunscreen use and skin type, with

lighter skinned individuals reporting more use. Similar findings were reported by Mermelstein and

Reisenberg (1992). In a sample of over 1770 adolescents, they report that over 30% of the female

12
subjects and almost 45% of male subjects reported never using sunscreen. Only 1/6 of the females

and half as many males identified themselves as using sunscreen most of the time.

In a study of 82 families at the beach, researchers attempted to compare parents who were

using sunscreen on their children with parents who were not (Maducdoc, Wagner, Jr., and Wagner,

1992). Children with a history of painful sunburns in the past were significantly more likely to be

wearing sunscreen due to parental intervention. Another study that examined sunbathing and

sunscreen use during a two-day weekend found that sixth graders who were sunburned on the first

day were significantly more likely to use sunscreen on the second day (Reynolds et. al 1996).

In contrast to most research, the AAD completed a survey in which more than half of

parents with children ages 12 or under reported using a sunscreen of 15 SPF or above on their

children (Robinson, Reigel and Amonette, 1998). However, no assessment concerning the regularity

of such sunscreen use was made. Thus, parents responses may have been influenced by social

desirability factors.

In Australia, a country with even greater incidence of skin cancer than the U.S., less than

1/3 of 3200 adolescents surveyed were found to be using sunscreen (Cockburn, Hennrikus, Scott,

and Sanson-Fisher, 1989). In an even larger study of 15,169 high school students in Norway, 75%

used a sunscreen with an SPF lower than six (Wichstrm, 1994). In this study, when sunbathing for

more than six hours, one third of these students said they used an SPF between 0 and 2, which falls

far below recommendations of SPF 15.

13
Sunscreen Use Among College Students

Vail-Smith and Felt (1993) found that less than 10% of a sample of about 300 college

students reported using sunscreen with every intentional UV exposure of 30 minutes or more.

Equally disappointing was the finding that six out of 10 males and four out of ten females admitted

to minimal use or avoidance of sunscreen. Leary and Jones (1993) examined a group of college

students and found that 41% did not understand the meaning of the SPF rating, while almost one

fifth were unaware that sunscreens have been demonstrated to reduce the risk of skin cancer.

Among this sample, sunscreen use was predicted by factors such as knowing someone who had skin

cancer, having a fair complexion, and believing that one has control over ones health. Still another

sample of 90 undergraduates reported using sunscreen less than half of their time in the sun

(Hillhouse, Stair, & Adler, 1996). In this study, even those students who used sunscreen reported

using an SPF below 15. In a sample of 905 participants at an outdoor event, just over 1/3 reported

sunscreen use on that particular day (Manion, Cloutier, & Klassen, 1997).

In an Australian sample of over 350 individuals interviewed by telephone, only 12% said that

they protect themselves every time they go into the sun. Over half reported such protection at least

most of the time, with one fourth protecting themselves only part of the time and another 8% rarely

or never protecting themselves from the sun (Clarke, William, and Arthey, 1997).

Sunscreen Use in the General Population

Based on a national survey, an estimated one fourth of white sunbathers in the United Sates

routinely use sunscreen at appropriate levels (Koh et. al, 1997). Sunscreen use was found to be

14
reported by women more than men. In addition, sunscreen use was found to have a positive

relationship with the level of education. As the level of education increased, so did sunscreen use.

A recently completed study (Turrisi, Hillhouse, Gebert, & Grimes, 1999) found a strong

relationship between individuals reported sunscreen behavior and the perceived efficacy of

sunscreen use. This research suggests that the use of sunscreen may depend on such variables as

perceived differences in sunscreen as well as knowledge of how and when to apply sunscreen.

Failure to use sunscreen properly may result in sunburns or skin damage, yet individuals who misuse

sunscreen may believe their burns resulted from an inadequacy in the product rather than from

their faulty application of the product.

Motives for Tanning

Suntanning is one strategy individuals use to attain greater attractiveness (Miller, Ashton,

McHoskey, & Gimbel, 1990). The tanned body is strongly promoted as attractive in magazine

advertisements and other media outlets. The positive association between a tanned body and

attractiveness has been demonstrated in several recent studies (Broadstock, Borland, Gason, 1992;

Hillhouse, Turrisi, Holwiski, & McVeigh, 1998; Johnson & Lookingbill, 1984; Keesling & Friedman,

1987; Lupton &. McGaffney, 1996; Miller et al., 1990; Reynolds et al, 1996; Vail-Smith & Felts,

1993; Wichstrm, 1994). In the Johnson & Lookingbill (1984) investigation, 72% of their 489

subjects believed that tanned skin was more attractive than untanned skin. Similarly, Vail-Smith and

Felts(1993) found 73% of 296 adolescents believed tanned skin to be more attractive than pale skin.

Therefore, it is not surprising that sixth graders who agreed with the statement that a tan makes

them attractive experienced longer sun exposure during a two-day holiday weekend (Reynolds et al.,

15
1996). In yet another study, when 68 parents were given the statement A tan makes people better

looking, 6 out of 10 parents agreed or were neutral (Foltz, 1993).

Sunbathers have also been found to perform more appearance-related behaviors than non-

sunbathers. Keesling and Friedman (1987) found that having a tan and sunbathing were closely

related to the individuals social networking system. Thus, for these subjects owning a tan was

associated with the presentation of an image of an attractive person. Therefore, the desire to have a

tanned body may relate more to an individuals concern with social opinion rather than to self-

satisfaction with appearance.

Another motive for tanning appears to be the perception that a tanned individual is healthier

than one without a tan (Broadstock et al., 1992; Johnson, & Lookingbill, 1984; Keesling, &

Friedman, 1987). In particular, the Johnson and Lookingbill study found that 78% of 489 subjects

believed that a suntan looked healthy. When researchers interviewed parents at the beach with their

children, over eighty percent of respondents shared the belief that a suntan looked healthy on their

children (Maducdoc et al., 1992). In another study conducted in France, mothers used health as a

primary reason for exposing their children to the sun (Grob et al., 1993). Broadstock, Borland, and

Gason, (1992) note that for the sunbather, the appearance of health may take priority over actual

health concerns.

Peer and Parental Influence

An examination of the development and incorporation of an individuals beliefs, attitudes,

and behaviors must include the influence of significant others. From a developmental perspective,

parental influence would usually be the initial and predominant influence during early childhood.

Rosenstock (1974, p. 379) states that children learn to adopt many health related habits and

16
practices which will permanently influence their adult behavior during the socialization process.

Using a large sample of children ranging in age from third to twelfth grade, Berndt (1979) found that

ninth grade or mid-adolescence is the period at which conformity to peers reaches a peak. Moving

on into adolescence, behaviors continue to be established that affect health in later life (Evans,

Gilpin, Farkas, Shenassa, and Pierce, (1995).

Lau, Quadrel, and Hartman (1990) emphasize that parents render models of both healthy

and unhealthy behavior. These researchers found modeling of behavior to be the most significant

avenue of parental influence. Parents choose their behavior as a result of the beliefs that they hold.

The beliefs held by the parents are thus conveyed to their children intentionally through training

efforts or these beliefs may be transferred unintentionally or incidentally. These authors found

evidence in a longitudinal study that the parental influence on the health beliefs and behavior of

their late adolescent children were relatively consistent over time (three years) after the child left the

home. These findings are consistent with the enduring family socialization model which purports

that health beliefs and behavior learned during childhood within the family remain stable throughout

life.

Lau et al. (1990) stated that any theory concerning the beliefs and behaviors of young adults

which neglected peer influence would be incomplete. It is from these interpersonal relationships

with both parents and peers that the image of self emerges within the adolescent. Similarly, Langer

and Warheit (1990) also theorize that self is constructed based on the beliefs, attitudes, and

behaviors of these significant others. Lau et al. (1990) found evidence that modeling is the foremost

process through which peers exert influence over each other. Yet, rather then a mere mimicry of

behavior, it is through negotiations with parents and peers that adolescents are influenced in their

decision-making process (Langer and Warheit, 1990).

17
 Although the influence of friends is a primary consideration, it should be recognized that

individuals, adolescents included, ordinarily control the selection of their friends and in so doing

may embrace friends with shared beliefs (Langer & Warheit, 1990). As adolescents witness the

behavior of others, they make decisions about who they will choose as friends and which behaviors

they will endorse. When this happens, the social group which is formed may be self-reinforcing in

such behaviors as suntanning, thereby confirming the behavior as positive. Therefore, any study

into health beliefs, attitudes, and behaviors should include the perceptions that the adolescent has in

regard to the beliefs, attitudes, and behaviors of significant others including most importantly

parents and peers.

On Sunbathing and Sunscreen Use

An example of parental influence through the modeling of sunbathing practices is suggested

by a study of sixth graders (Reynolds et al, 1996). This study found that those who reported having

parents who lie in the sun to get a suntan, had longer sun exposure than those who did not.

An examination of the literature specific to adolescents use of sunscreen found that

adolescents were more likely to use sunscreen if a best friend did or if they had parental guidance

(Banks et al., 1992). This finding could have a negative impact on sunscreen use given the findings

of Foltz (1993) that while 73% always used sunscreen on their children at the beach, only 3%

applied it on their children when they played outside at home. These same parents completed a

survey that indicated their knowledge of the need for protection from every type of sun exposure,

yet their behavior was not consistent with that knowledge. The personal use of sunscreen by parents

appears to be a primary determinant of whether they use sunscreen on their child (Zinman,

Schwartz, Gordon, Fitzpatrick, & Camfield, 1995). Continued use by the child may be related to the

18
modeled use of sunscreen by the parent. It could also be reflected by the adoption of the belief

system of the parent in regard to sunscreen use. Perceived parental influence was a significant factor

in sunscreen use by the sample of 2029 adolescents in the Cockburn et al. (1989) study. For

example, among those using sunscreen, 42.2% used a brand selected by their parents.

In a large Norwegian sample, adolescents sunbathing efforts were strongly related to those

of friends, as sunscreen use was predicted by peers use of sunscreen (Wichstrm, 1994).

According to a study in the Southeastern United States, tanning behaviors were associated with the

perception that the individuals friends were also tanning (Reynolds et al., 1996).

Cockburn et al. (1989) found evidence that teenagers had a desire to maintain an acceptable

image among their peers. Responses indicated that noncompliance with sunscreen use was related to

the image the adolescent perceived would be portrayed to his/her peers. A positive association

existed between those who failed to use sun protective measures and those who perceived their use

to promote a negative image of themselves to others.

Adolescents perception that sunscreen use portrays a negative image among their peers may

suggest to them that nonuse portrays a positive image. Because of the positive association between

a suntan and attractiveness, the social reward for a suntanning behavior is therefore evident. These

immediate rewards tend to distort an adolescents ability to exercise behavioral control. McReynolds,

Green, and Fisher (1983) predict that regardless of the promise of future reward, adolescents have

difficulty choosing a healthy behavior over a present alternative of social reward.

Sunburn

Because sunburns are associated with potential for future incidence of skin cancer, a number

of studies have investigated sunburn occurrence through a variety of methods. By telephone

19
interview one study found that within a previous two-week period, adolescents aged 11-19 with skin

types I and II had experienced an average of three or more sunburns (Robinson, Rademaker,

Sylvester, & Cook, 1997). An extensive number of moderate risk skin types reported sunburns at

least annually when unprotected by sunscreen. Another telephone based study found seven percent

of 285 children had experienced a sunburn on the weekend preceding the study (McGee, Williams,

& Glasgow, 1997).

Studies investigating risk factors for squamous cell carcinoma (SCC) have found that

blistering sunburns to a particular area of the body have been found to be positively association with

SCC (English et al., 1998). Bajdik, Gallagher, Hill, and Fincham (1998) found this to be more

profound for sunburns experienced during the ages of 5 to 15 years.

The findings of Green et al. (1985) suggest that individuals who have been subject to

repeated sunburns have a higher risk for melanoma. This same study reports that risk for melanoma

is more than doubled for those who have experienced six or more sunburns. The results of this

study were supportive of the theory that melanoma results from the effect of acute, intermittent,

episodic exposures rather than the effect of cumulative exposure. Although the effects of the

damage are not diagnosable until 20 or more years later, for melanoma, solar injury is a greater risk

factor than age (Epstein, 1983).

It is interesting to note that a study by Reynolds et al. (1996) found that when questioned

regarding the previous two days of exposure, sixth graders who used a sunscreen with an SPF of 15

or greater, reported a higher incidence of sunburn. This would appear to negate claims that

sunscreen protects against sunburn. On the contrary, this information agrees with other studies that

suggest that individuals who use sunscreen may increase their length of time of exposure due to a

belief that they are safe from solar injury while using sunscreen. A false sense of security may be

20
promoted by the marketing tactic which suggests that sunscreen offers a safe tan (Autler et al. 1997).

Furthermore, many individuals fail to reapply sunscreen as recommended by the manufacturer. Still

others believe that there is no limit to the amount of time they are exposed as long as sunscreen is

continuously reapplied. Sunscreen is effective for a specified, yet limited number of hours per

exposure no matter how many times it is applied. Therefore, a lack of understanding of the

limitations of sunscreen may explain these findings that suggest increased sunburn among sunscreen

users.

Longer sun exposure has been reported by adolescents who have a skin type which always

burns and who have the option to avoid the sun (Reynolds et. al, 1996). This may suggest a more

persistent effort to obtain a tan among this group. These authors make the point that such findings

may indicate a desire among lighter skinned adolescents to tan and appear more attractive.

According to the International Agency for Research on Cancer (1992), sunscreen allows longer

periods of time to be spent in the sunlight resulting in exposure to higher amounts of UV

wavelengths. Because melanomas are believed to be related to these brief intense periods of UVR

exposure at an early age (Bargoil & Erdman, 1993; Stern et al., 1986), it is alarming to find young

adolescents engaged in this type of UV exposure.

Prevention

Prevention may be as simple as the intentional avoidance of sun exposure by a number of

means. The decision to tan or not to tan is typically a controllable behavior (Miller et al., 1990;

Rossi, Blais, Redding, & Weinstock, 1995). Keesling and Friedman (1995, p. 478) posit that since

most unprotected sun exposure is under an individuals voluntary control, skin cancer could

theoretically be largely preventable by psychosocial influences. Studies are available that show that

21
a significant number of individuals intentionally work on a tan (Johnson & Lookingbill, 1984). A

publication of the National Cancer Institute (1995) advises that childhood is the time to begin

preventative habits because skin cancer is related to lifetime exposure. Recommendations include

the avoidance of exposure to the midday sun, use of protective clothing, and the use of sunscreen

(NCI, 1995). Use of the appropriate sun protection factor (SPF) of sunscreen is encouraged to

protect against the UVA and UVB radiation which causes sunburn and subsequent skin damage

resulting in skin cancer later in life. A sunscreen with an SPF of 15 used regularly during the first

eighteen years of life could potentially reduce the risk of developing non-melanoma cancer by 78%

(Stern et al., 1986).

Studies suggest that regular and appropriate sunscreen use is practiced by only a small

percentage of individuals. Some studies have found that nine percent of participants report always

using sunscreen (Banks et al., 1992) or use with intentional sun exposures of 30 minutes or longer

(Vail-Smith & Felts, 1993). While Hill et al. (1992) found that 21% of their sample reported use of

sunscreen, only 55% had used a SPF of 15 or above. When researchers used a liberal definition of

adequate use of sun protection measures, 30% were found to fall in this category (Cockburn et al.,

1989). Sunscreen was rated as the first choice for sun protection by this sample, with 53.9%

choosing their own brand of sunscreen. This sample exhibited a negative relationship between ease

of tanning and use of sunscreen. Sunscreen use in a Norwegian study was 90%, although only 25%

of those used an adequate SPF and only half reapplied an adequate number of times (Wichstrm,

1994).

Results of a national survey show that only a quarter of sunbathers use sunscreen at

recommended levels (Koh et al., 1997). Failure of individuals to use sun protection has resulted in

22
the U. S. Public Health Year 2000 objective which sought to achieve compliance by 60% of the

people to use these precautions.

Interestingly, the study by Banks et al. (1992) found that sunscreen was the preferred

method of sun protection. Susceptibility to sunburn has been shown to increase the likelihood of the

use of sunscreen (Cockburn et al., 1989). This agrees with the finding by Cockburn et al. that skin

type correlates with use of protective measures.

In consideration of the failure of a significant number of individuals to use sunscreen

in an appropriate manner, it is well to question the reasons for this noncompliance.

Well-informed adolescents and the mothers of young children have reported a belief that the risk of

sun exposure is exaggerated by the media (Grob et al. 1993). Leary and Jones (1993) suggest that the

public does not appear to be convinced of the seriousness of the problem. Another factor may be

the perceptions of individuals concerning the effectiveness of sunscreen (Vail-Smith & Felts, 1993).

Furthermore, there may be a tendency of adolescents to view skin cancer as an adult issue

which is not applicable to them (Gillespie, Lowe, Balanda, & Del Mar, 1993, as cited in Lupton &

Gaffney, 1996). In addition, it is likely that they value the immediate reward of becoming more

attractive in the present to the potential for better health in a future which seems very distant

(Jeffrey, 1989). Studies of time perception indicate that time intervals close to the present are viewed

with greater importance than time intervals in the future (Cohen, 1964, as cited in Jeffrey, 1989).

This is not surprising when you consider that in evaluating long and short-term risks, individuals

tend to overvalue short term threats (Svenson, 1977, as cited in Jeffery, 1989). For this reason,

adolescents may have difficulty recognizing the importance of sun protection since they may

perceive this as a problem of adulthood which may or may not occur in the far distant future.

23
 Theories of Health Behavior

Health behavior is described as any behavior which affects an individuals condition of

health. Much research has been devoted to establish relationships between certain health practices

(behaviors) and health status. Once behaviors are established to be either health enhancing or health

risky, efforts are often made to examine motivational factors involved in the continuance of such

behaviors. Educational interventions are then developed to create awareness and encourage

individuals to adopt healthier behaviors as well as to eliminate the behaviors which have been

determined to be disease risk factors.

As a part of this process, social scientists gather data about beliefs, attitudes, and

motivational factors related to performing or abstaining from health risky behaviors. These

researchers evaluate educational resources available to research participants as well as studying

parental or peer influences on behavior. The social scientists goal is to develop programs to

facilitate a positive change in health behavior. Due to the numerous variables effecting health

behavior, a number of theories have arisen in this area of research. These theories are not always

incompatible with each other, but often offer complimentary views which are useful to our

understanding of health behavior. The present study attempts to integrate the constructs from

several of these theories in the development of an instrument to examine adolescents beliefs,

attitudes, and practices regarding suntanning and sunscreen use behaviors. While the Behavioral

Alternative Model provides the theoretical structure for examining these variables, the Health Belief

Model (HBM), and the Pre-adult Health Decision-making Model (PAHDM) will be used as well.

24
The Health Belief Model (HBM)

This model began to be developed in the early 1950s as researchers explored the decision-

making process used by individuals regarding whether to accept illness detection and prevention

services for health purposes. Variables affecting health related decision-making were discovered to

include both perceived susceptibility to illness or disease as well as perceived benefits from both

prevention and early detection services. The perceived benefits component of this early model did

not consider either costs or barriers. However, the developing model began to accumulate evidence

that individuals consider both the cost involved in making a change as well as barriers which have to

be overcome. Later studies incorporated the concept of motivation into the model (Rosenstock,

1974). In time, the models use was extended into various areas of health related research.

The HBM (Rosenstock, Strecher, & Becker 1988) hypothesizes that health-related action

depends on the occurrence of the following factors: (1) The existence of health concern (2) The

belief that one is vulnerable or threatened by a health problem (3) The belief that following a health

recommendation (making a behavioral change) would benefit in reducing that threat at an acceptable

cost. According to the HBM, environmental cues must exist which stimulate the individual to make

a decision to reduce a health risky behavior. Such environmental cues form a foundation for a

change in behavior to occur. These cues might include the illness or death of a friend or family

member (Langer & Warheit, 1992) as well as symptoms of disease or even a media message (Cody &

Lee, 1990).

The Health Belief Model in Related Studies

The Health Belief Model was evaluated as early as 1952 by Hochbaum in examining what

might predispose patients to obtain a chest X-ray for the detection of tuberculosis.

25
Use of the HBM to examine susceptibility was extended to other areas including: uterine cancer

(Flach, 1960), rheumatic fever (Heizelmann, 1962), and influenza (Leventhal, Hochbaum, &

Rosenstock, 1960). These researchers studied patients beliefs of risk of acquiring the specific

medical condition in question. As a result, risk became a primary component of the theory.

Kegeles (1963) extended use of the HBM to perceived severity as he studied asymptomatic

patients use of preventative dental check-ups. In studying perceived severity, he looked at whether

there was a relationship between the patients perception of severity and willingness to use these

services. For instance, an individual who rated high in his perception of the severity of a toothache

might be more likely to attempt to avoid a toothache by using preventative services for early

detection of tooth decay.

The use of the HBM continued through the exploration of not only perceived susceptibility

to disease, but also perceived benefits from treatment. In 1970, Heinzelmann and Bagley extended

the use of the HBM to study the reasons participants might be engaged in physical activity programs

(cited in Rosenstock, 1974). The HBM also has been used in researching childrens perceptions and

health-motivation (Gochman, 1970). More recently, a Childrens Health Belief Model has been

developed as an adaptation of the HBM (Bush & Iannotti, 1990).

The continued use of the model over many years supports its reliability as a tool for

understanding preventative health behavior. From the time when individuals were skeptical about

obtaining a chest X-ray to the more recent studies of adolescent sexual behavior in regard to AIDS

(Langer & Warheit, 1992), the HBM has been used in understanding public reception to the latest

health practices. As new technologies, treatments, and recommendations for self-care have

appeared, the HBM has been used to help understand and facilitate the adoption of the latest

prevention and detection health practices by the general public.

26
Pre-Adult Health Decision-making Model (PAHDM)

Langer and Warheit (1992) have proposed a model to study adolescents health related

attitudes and behaviors. This model was the culmination of a study that examined the relationship

between adolescents decision-making processes and AIDS-related knowledge, attitudes, beliefs,

behaviors, and interpersonal skills (KABBS) (Langer, Zimmerman, Warheit, & Duncan, 1993).

The PAHDM hypothesizes that human behavior involves interacting cognitive, emotional,

and symbolic processes which are learned, rational, modifiable, and dynamic (Langer & Warheit,

1992, p. 933). This model assumes that directedness /orientation is fundamental to adolescent

decision-making. An individuals directedness can be thought of as the main resource used when

making decisions. When an individuals orientation is inner directed, personal norms and values

are called upon for decision-making, whereas an other directed individual would rely more heavily

on peers or reference groups to direct his decision-making (peer-directed). Directedness/Orientation

is similar to the construct known as self-monitoring (Snyder, 1974).

In a given situation, directedness may be peer-directed, parent-directed, or self-directed

according to the individual. While directedness is the main component of the model, the PAHDM

specifically focuses on how reference groups guide or direct decision-making as well as strengthen

the attitudes, beliefs and behaviors related to risk (Langer & Warheit, 1992). This model assumes

that the decision-making style of adolescents may differ from that of adults. While adult decision

models assume that adults are free and autonomous, this model proposes that adolescents are

constrained by the artificial control of adults (Langer & Warheit). Therefore, models of health

behaviors which have been designed to predict behavior in the less restrictive environment of the

adult may not be applicable to adolescents.

27
 Three basic theoretical perspectives are used to form a foundation for this model. First,

adolescence is the time in which the construction of self takes place (Langer & Warheit, 1992).

According to Erickson (1950) construction of self is the central task of mid-adolescence. During this

time, the individual begins to differentiate from the self created by his parents, moving toward peer

influence and finally integrating these parental and peer influences into his unique personal and

social characteristics (Langer & Warheit). An integral part of this process is the influence of the

attitudes, beliefs, and behaviors of significant others. This group of influential individuals become

the reference used by adolescents as they make decisions. Second, the PAHDM assumes that in

addition to a socially interactive process, adolescent decision-making is actually negotiated with

others. As adolescents discuss their beliefs with each other, they gain different insights and new

perspectives. In the process, their beliefs are either challenged to change or reinforced to remain

intact. During this stage of development, they come to better understand what they believe and are

able to complete the decision-making process in regard to their behaviors. Third, the theory depicts

this decision-making process as the processing of external information (knowledge and beliefs from

the environment) as inputs, and the establishment of attitudes and behaviors as outputs.

Although the maturational or developmental perspective from which it views the

progression from childhood to adulthood makes it unique, the PAHDM integrates aspects from

several current health behavior models such as Social Learning Theory (Bandura, 1977), the Health

Belief Model (Rosenstock, 1974), Decision-Making Model (Janis & Mann, 1977), and the

Ajzen-Fishbein Model (Ajzen, 1982; Ajzen & Fishbein, 1980).

28
Behavioral Alternative Model

Using decision theory as its basis, Jaccard (1981) developed a behavioral alternative model of

social behavior. The model is used to examine situations in which an individual has the occasion to

perform one of several possible alternative behaviors. The performance of one of these behaviors

prohibits the performance of any of the other choices. On the most basic level (Jaccard, 1981;

Jaccard & Wood, 1988), one can envision two behavioral alternatives, (1) performing a behavior

(e.g., using sunscreen) or (2) not performing a behavior (e.g., not using sunscreen). Expanded

further, the individual will not only decide whether or not to perform one particular behavior, but

will also likely have at least several alternative choices of behavior. This theoretical model considers

the decision process involved in making such choices.

The stages of this decision process include: (1) the formation of behavioral alternatives, (2)

the examination of these alternatives, and (3) choosing between the alternatives. When making such

choices, Jaccard (1981) proposes that the individual will evaluate the alternatives and choose the one

toward which he feels most positive. One might envision a scale or affective dimension with positive

and negative endpoints. Each choice might be placed in a position according to the individuals

evaluation of how positive he feels about that alternative. Several items might be placed in varying

positions on that scale, but the individuals chosen behavior would be the alternative which lies

closest to the positive endpoint. According to Jaccard (1981, p 289) attitude is defined as, the

location of an attitude object (behavioral alternative) on a bipolar affective dimension. Therefore,

the behavioral alternative chosen will concur with the individuals attitude.

Furthermore, these attitudes will be based on the individuals perceptions or cognitions

toward the behavior, which evolve from experiences previously encountered, vicarious learning, and

influence from other sources (e.g., family members, peers, and media) (Turrisi et al., 1999). Thus, in

29
a given situation, the individual must choose to perform one alternative from a set of behavioral

alternatives and the individual may be thought to possess an attitude toward the performance of

each of the alternative behaviors. In regard to its locations on the bipolar affective dimension, the

attitudes are directly measurable using standard attitude-scaling techniques. The individual will

decide to perform the behavior toward which the most positive attitude is held, and the decision, in

turn, influences the individuals actual behavior (Jaccard, 1981).

For clarification, an individual may possess a positive attitude toward watching television,

but may have an even more positive attitude toward going to a movie. Given the opportunity to go

to a movie, it is not likely that he/she will stay home and watch television, although he/she has a

positive attitude toward that behavior. It is assumed that the behavior chosen will be the one to

which the most positive attitude is held. The behavioral alternative model is concerned with the

attitudes toward a behavioral alternative relative to other behavioral alternatives. When such

attitudes are compared, the alternative toward which the most positive behavior is held should

represents the predicted behavior (Jaccard, 1981).

Jaccards (1981) study found that when individuals view their behavioral alternatives as

equivalent, these individuals will continue to perform the behavior they have been performing in the

past rather than assuming any new behaviors. Individuals may even fluctuate between alternatives

resulting in decisions which are unstable over time. Therefore, accurate long-range prediction of

behavior is unlikely. Even so, this model allows the researcher to identify those individuals for

whom this is the case. In order to make accurate predictions regarding behavioral choices, the

behavioral alternative model states that attitudes toward all of the relevant alternatives should be

measured (Jaccard).

30
 There are several options available to apply this model in order to evoke change in health

risky behaviors: (1) to make the healthier alternative more positive, (2) to make the riskier alternative

more negative, or (3) some combination approach. The chosen strategy will be determined by the

mean attitude scores for the two alternatives. For example, suppose the attitude toward sunbathing

at noon is highly positive, and the alternative of choice is to avoid sunbathing at that time of day.

An attempt to make sunbathing at four in the afternoon more positive will not achieve the desired

results. First, it would be necessary to lower the attitude toward the first alternative (sunbathing at

noon) to some extent. Then, one could proceed to raise the attitude toward the desirable alternative

(sunbathing at four in the afternoon) Therefore, the relationship between alternatives may warrant

the employment of different strategies to strengthen the attitude toward the desired choice.

When compared to the traditional attitude model, the behavioral alternative model has been

shown to be superior (Jaccard, 1981). Traditional models are cumbersome, requiring participants to

yield information concerning other variables that might influence behavior. In contrast, the

attractive feature of the behavioral alternative model is its ability to predict behavior without

information traditionally thought to be essential. It offers good or better accuracy than traditional

models as participants are given an opportunity to examine the choice between alternatives. There is

no need to know desired outcomes or psychological processes involved in the process. The

behavioral alternative model is a clear-cut procedure which appears to accurately elicit the desired

information without unnecessary and burdensome information gathering processes (Jaccard).

Behavioral Alternative Model in Health Related Studies

This cognitive approach has been utilized to study a number of health related issues. The

behavioral alternative model has been used to study destructive behavior (Piazza, Moes, & Fisher,

31
1996); alcohol-impaired driving tendencies (Turrisi et al., 1997); drunk driving (Turrisi & Jaccard,

1992); artificial tanning tendencies (Hillhouse et al., 1998); and cognitive variables relevant to

sunbathing (Turrisi, Hillhouse, & Gebert, 1998)

More poignant to the current study is a recent study of cognitive variables relevant to

sunscreen use (Turrisi et al., 1999). The two hundred thirty subjects of college age were assessed

regarding behavioral tendencies and attitudes toward sunscreen use. In addition, the questionnaires

administered examined both internal-based and external-based cognitions relevant toward sunscreen

use and sunscreen behavioral tendencies. Factors examined were the perceived need to use

sunscreen, perceived consequences, perceived efficacy, and social-normative influence. The goal of

the study was to define those cognitions underlying the attitudes toward performing the behaviors

under investigation, i.e. sunscreen because these cognitions are more responsive to modification in

short-term educational settings (Jaccard, Turrisi, & Wan, 1990; Jaccard & Wilson, 1991; Turrisi,

Jaccard, & McDowell, 1997).

Most studies have examined one or two variables at a time in relations to sunscreen use. This

study differs from other studies by assessing the multivariate influence of variables simultaneously.

The first variable studied, perceived need, was placed in the context of externally based information

about the weather, temperature, and time of day. It was anticipated that internally based information

such as skin type would influence the cognitions relevant to decision making.

Perceived consequences of sunscreen use was assessed for both negative end result

(reduces flattering effects of suntanning) and positive outcome (prevents skin damage and skin

cancer). Since individuals differ in their perceptions, their decisions concerning suntanning should

also differ due to their perceptions. Those who perceive their appearance will be improved by

32
suntanning will be less likely to use sunscreen. Whereas, those who perceive their skin may be

damaged from the effects of the sun will be more likely to protect their skin with sunscreen.

Perceived efficacy of sunscreen was assessed to determine any relationships which existed

between the individuals perceptions of the effectiveness of sunscreen and subsequent use. In

addition, the study examined general knowledge about sunscreens as well as specific knowledge as

demonstrated by sunscreen usage since perceived efficacy would likely be influenced by these

factors. Social-Normative influence was examined by studying the potential effect of friends and

family on sunscreen use.

Turrisi et al. (1999) found that temperature, weather, and time of day were all significant

predictors of sunscreen use. Of particular importance, it was demonstrated by this study that

sunscreen use increased as perceived efficacy increased and perceived efficacy increased as general

knowledge about sunscreen use increased. As individuals understanding of how and when to apply

sunscreen increased, so did sunscreen use.

Statement of the Problem

There is extensive evidence that annual incidence of skin cancer continues to rise although

protection from ultraviolet exposure exists in the form of sunscreen. Currently, U.S. citizens can

expect that the chances are one in five that skin cancer will develop over the course of a lifetime

(AAD, 2000). Damage from ultraviolet radiation incurred during childhood and adolescence is

believed to initiate skin cancer growth, although the cancer may not appear until twenty or thirty

years later. Therefore, it is important that efforts be made to prevent sun damage from occurring to

individuals in this age group. During adolescence, young people begin to assume decision-making

responsibility and develop decision-making skills. This is an important age in which successful

33
interventions can have strong effects on future behavior. In order to develop these interventions, it

is critical to better understand the skin cancer related beliefs and behaviors of individuals in this

period. For these reasons, this study will focus on the middle school children (11 to 14 years old).

Existing studies in regard to suntanning and sunscreen use among adolescents are limited.

As this group may differ in decision making approach, it is important to study the beliefs, attitudes

and behaviors of this age group. Therefore, the present study will examine a middle school age

sample using the behavioral alternative model.

The following hypotheses were made for the present study:

(1) Individuals who have the most positive attitudes toward suntanning will be more likely to

engage in suntanning behaviors.

(2) There will be a positive relationship between sunscreen efficacy and sunscreen use.

(3) There will be a positive relationship between perception that peers and parents have a positive

attitude toward sunscreen use and individuals sunscreen use.

(4) Sunburn incidence will be predicted by sunscreen use and sunbathing behavior.

34
 CHAPTER 2

METHODS

Subjects

One hundred parent-child family units were recruited for this study. To be eligible to

participate, one family member had to be in the middle school age group of between 11 and 14 years

of age. To complete the family unit, one parent participated.

To avoid an extended screening for middle school students using local phone books, middle

school yearbooks were used to obtain the names of potential participates. Surnames were cross-

referenced with local phone directories to focus only on surnames found in the middle school

directories. Extremely common names were given last priority as a screening tool. This process was

completed using yearbooks from a county middle school in Southwestern Virginia and from a city

middle school located in East Tennessee.

Phone contacts were made just prior to and after Labor Day weekend in late summer. Once

phone contact was made, and it was established that there was a middle school student within the

household between the ages of 11 and 14, the interviewer asked to speak with an available parent.

The parent was briefed concerning the purpose of the study and asked if he/she would be willing to

answer three questions and give permission for his/her child to answer a few similar questions.

He/she was advised that the interview with the child would take approximately 5 to 10 minutes and

the child would be allowed to decide if he/she wished to participate.

35
 Measures

Parent/Student Questionnaire

The study makes use of a two-part questionnaire. The first part consists of questions to be

answered by the parent to assess parents perceptions of the childs previous years summer

sunburns, as well as current and usual suntanning behavior. Students questions collect

demographics, recent and previous sunburn history, sunscreen use, perceived skin sensitivity,

knowledge and beliefs about risk, family history of skin cancer, parental and peer influence,

appearance motivation, health motivation, and belief in efficacy of sunscreen. Scenarios were

provided to provoke subjects to make decisions as to preferred choices when given behavioral

alternatives (see Appendix B).

Demographic Variables. Students were asked to report their gender, age, and skin color. To

determine skin color, the student was read a series of responses to complete the statement My

Skin These responses ranged from (1) Always burns, never tans to (6) doesnt burn, its

black on a six-point Likert type scale. These responses were derived from a procedure highlighted

by Fitzpatrick (1975) to more accurately differentiate skin types. This method of skin typing is

commonly used in research. Its credibility is apparent in that the American Cancer Society (1998)

published directives for graduated choices of sunscreen sun protection factor (SPF) based on this

typing system. Skin type I includes individuals who have a nature to burn easily, never tan, and who

have skin which is extremely sun sensitive. Skin type II includes individuals who also burn easily,

but do tan minimally, with skin that is average in skin sensitivity. Skin type III is made up of

36
individuals who burn sometimes, have light brown tanning, and have sun sensitive skin. Skin type

IV includes individuals who have a minimal experience with burning, carry a moderate brown tan,

and are minimally sensitive to the sun. Skin type V is made up of those individuals who are not

sensitive to the sun, rarely burn, and tan well. The last group, Skin type VI, is insensitive to the sun,

never burn, and have darkly pigmented skin.

Recent and Previous Sunburn History. Both parents and students were asked for the

adolescents recent and previous sunburn history. Parents were asked to recall or estimate the

number of sunburns the child had the previous summer. In addition to this same question, students

were asked the number of sunburns they have experienced within the last month.

Sunscreen Use. Adolescents were asked to estimate the percentage of the time that they

used sunscreen over the summer. They were asked to choose the SPF factor of sunscreen they

commonly apply using the following scale: 4, 8, 15, 30+, or not sure.

Efficacy of Sunscreen. To more accurately assess the domain of sunscreen use, we

investigated perceived efficacy of sunscreen in particular. Using a five point Likert type scale

(strongly agree, moderately agree, neither, moderately disagree, strongly disagree), participants were

given statements to evaluate regarding the effectiveness of sunscreen (I dont wear sunscreen

because I dont think it really works; I dont believe that I will get a sunburn by not using sunscreen;

If I continue to go outside without sunscreen, odds are that I will eventually get skin cancer).

37
 Skin Sensitivity. Although skin sensitivity can be determined by the skin type discussed

earlier, additional questions were designed to more accurately assess this domain. Adolescents were

asked to describe a typical sunburn for them by rating that sunburn on a four point Likert type scale

(not at all; slightly; moderately; extremely) as to the amount of burn, painfulness, and difficulty

wearing clothes when sunburned. Skin sensitivity along with skin type correlate with future

incidence of skin cancer (ACS, 2000).

Knowledge and Beliefs about Skin Cancer. To assess the knowledge and beliefs concerning

skin cancer, participants rated their agreement with four statements using a five point Likert scale

ranging from strongly agree to strongly disagree. This section assesses the knowledge of melanoma

(melanoma is the most serious type of skin cancer), hair color as a risk factor (redheads and blondes

are at a greater risk for skin cancer), the safe way to avoid sunburns (the safe way to avoid sunburns

during the summer is to get a base tan), and ability to judge sun burning as it happens (it is common

for people to fail to feel sunburned even though they are).

Family History. Having a family member with skin cancer may have a bearing on an

individuals decision to participate in behaviors which are considered risky. Therefore, students

were given a single statement someone in my family has/had skin cancer, to which they

responded with true, false, or dont know.

Social Influence. Adolescents have been found to be influenced in their health behaviors by

both their parents and peers (Banks et al., 1992; Langer & Warheit, 1990; Lau et al., 1990). Because

these social-normative influences may explain significant amounts of variance in behavior ( Turrisi

38
et al. 1999), questions were randomly placed to assess peer and parental influence (I feel

uncomfortable if I am pale and my friends have a tan; Most of my friends try to get a tan; My friends

keep their skin healthy by using sunscreen; My friends notice when I have a tan; I only wear

sunscreen if my mother/father makes me wear it). Such questions required response on a five point

Likert type scale ranging from strongly agree to strongly disagree.

Appearance Motivation. To assess the association between a tanned body and attractiveness

discussed in the literature ( Broadstock et al., 1992; Keesling & Friedman, 1987; Miller et al., 1990),

the current study asked subjects for their agreement with a number of statements relating to their

perceptions about the relationship between a suntan and attractiveness (A tan makes me look good;

How you look influences how many friends you have). Again, a Likert type scale was used with

responses ranging from strongly agree to strongly disagree.

Health Motivation. Although inaccurate, it is believed by some that a tanned person is

healthier (Broadstock et al., 1992; Johnson & Lookingbill, 1984; Keesling & Friedman, 1987). For

these individuals the appearance of health may take priority over actual health concerns (Broadstock

et al.). Using the five point Likert-type scale employed in previous questions for agreement with

responses ranging from strongly agree to strongly disagree, adolescents were provided

statements to assess their cognitions in regard to health (I think I look healthier with a tan; Being

healthy and physically fit is more important to me than most people).

Alternative Behavioral Choices. The theory of alternative behavior recognizes that

individuals have a range of choices available to them in any given situation. Consistent with this

39
theoretical model, this study presented each respondent woth three behaviors that they might

engage in with their friends on a really hot, summer day (sunbathe, go to the movies, stay inside and

watch TV). Respondents were asked to rate how they felt about performing each option using a

Likert-type scale (1= very bad to 5= very good).

Following this general rating of the three alternatives, respondents were asked to give ratings

on a series of statements concerning the advantages and disadvantages of each of the three

alternatives (e.g., I think watching television is boring, My friends like going to the movies, etc.)

using 5-point Likert-type scales (strongly disagree to strongly agree).

Procedure

Prior to recruitment, the present study was reviewed and approved by the Institutional

Review Board of East Tennessee State University in Johnson City, Tennessee. Subjects were

recruited on a voluntary basis. Subjects were instructed that all information supplied to the study

would remain anonymous, that their participation was voluntary, and they were fully instructed in

regards to their rights as research participants. Subjects were advised that study results would be

available from Dr. Joel Hillhouse or Billie H. Murray after study completion. Subjects were

informed that they had the right to discontinue study participation at any time, and were instructed

to be honest in completion of questions asked by the researcher. Parent subjects were asked for

permission to interview adolescents and adolescents were given the opportunity to accept or decline

the invitation to participate even if the parents had given permission for them to participate.

40
 CHAPTER 3

RESULTS

Demographics

There were 100 respondents (71 females; 29 males) who agreed to participate in this study.

Participants ranged in age from 11-14 years (M =13.09, SD = .922). Skin type was distributed as

follows: skin type I = 4% skin type II = 19%, skin type III = 65%, skin type IV = 12%,

skin type V = 0%, skin type VI = 0%. A total of 52% reported having been outdoors specifically to

tan within the past three weeks (mean self-reported times outside to tan = 2.22 occasions ,

males = 1.59 occasions, females = 2.48 occasions; t= -2.617 , p < .05).

Adolescents reports of time spent outdoors during which they were wearing sunscreen

ranged from 2% to 100%. As a group, 59% reported using sunscreen 50% of the time or less. Only

24% reported using sunscreen 75% or more of their time outdoors. Only four percent reported

using sunscreen every time they went outdoors. Females reported greater sunscreen use than males

(females = 54%; males = 33%). Eighty-three percent of participants reported that when they used

sunscreen, they applied sunscreen with an SPF of 15 or more.

This study also examined the time duration for each incident of intentional suntanning.

Time durations reported ranged from less than one hour to between three to four hours. Females

again reported longer time periods spent engaged in intentional suntanning with a mean of 1.4

hours, while the male adolescents spent slightly less with a mean of 1.2 hours.

Reported incidence of sunburns during the prior month ranged from none to twenty, as

did sunburn incidents reported from the previous year. It was interesting to note that 75% reported

at least one sunburn during the previous month, while 92% reported the incidence of sunburn the

41
summer of the previous year. Female adolescents reported a mean of 3.1 sunburns during the prior

month, while male adolescents reported 1.2 sunburns during the same period. When recalling

sunburns from the previous summer, female adolescents again reported a higher occurrence with a

mean of 6.6 sunburns as compared to a mean of 4.4 for male adolescents.

Examination of Gender and Skin Type Differences

Overall gender and skin type differences in suntanning behavior, sunburn history, sunscreen

use, skin sensitivity, knowledge and beliefs about cancer risk, social influence

(i.e. peer and parental influence), appearance motivation, health motivation, and attitudes derived

from behavioral alternative choices were examined using multivariate analysis of variance

(MANOVA). Each MANOVA was performed with suntanning behavior, sunburn history,

sunscreen use, skin sensitivity, knowledge and beliefs about cancer risk, social influence (i.e. peer and

parental influence), appearance motivation, health motivation, and attitudes derived from behavioral

alternative choices serving as dependant variables. The MANOVA results indicated an overall

significant difference for gender (Pillais = .56, F [28,64] = 2.91, p < .001). Examination of results

revealed a significant gender difference for the belief that "looks influence the number of friends

one has, with male subjects more likely to believe this statement to be true. Areas in which

female adolescents were significantly different from males was their belief that most of their friends

try to get a tan, that melanoma is the most serious type of skin cancer, and that redheads and

blondes are at a greater risk for skin cancer. Females also reported significantly more sunscreen use,

times outside specifically to tan, and the difficulty of wearing clothes when they have a typical

sunburn. No overall differences on any of the dependant variables appear between skin types.

42
 Examination of Sunburn History and Sunscreen use

Suntanning and sunburn history reports were socially validated by conducting a

2-tailed Pearson bivariate correlation examined the relationship between a parents and childs

responses to the three questions regarding the suntanning/sunburn history. For all three questions,

responses of parents and adolescents correlated significantly (p < .01). Refer to Table 1.

TABLE 1

PEARSON BIVARIATE CORRELATION OF PARENT/CHILD RESPONSES

Child Child Child

Self-report Self-report Self-Report
Tan Hours in Sun Sunburns Last
Summer
Parent:: Child Tan .610 .296 .174
p < .001 p < .01 p > .05
Parent: Childs Hours in Sun .265 .399 .100
p < .001 p < .001 p > .05
Parent:: Childs Sunburns .187 .048 .416
Last Summer p > .05 p > .05 p < .001

Stepwise hierarchical regression analysis was used to examine both current summer and past

summer sunburn history as predictors of suntanning behavior. Demographic variables (age, sex, and

skin type) were controlled for by being entered first into the equation. These demographic variables

did not contribute significantly to sunburn history variance. Next, attitude and belief predictors

were entered including tanning attitudes, attitude toward a healthy lifestyle, attitudes toward

sunscreen use, skin cancer knowledge, family member skin cancer experiences, attitude toward

43
watching television, and attitude toward going to the movies. The regression results were not

significant for either current or previous summer sunburn history.

Sunscreen attitudes were also studied using regression analysis, again controlling for the

demographic variables (age, gender, and skin type) by entering them into the equation first. Next,

attitude and belief variables (tanning attitude, healthy lifestyle attitude, knowledge, family incidence

of skin cancer, television attitudes, and movie attitudes) were entered. Although the demographic

variables contributed no significant variance, the attitude and belief variables entered in the second

step were found to account for a significant 15.3% amount of the sunscreen attitude variance ( F

[3,99]= 51.67, p < .05). Examination of the regression beta coefficients revealed significant s for

gender ( = 2.60), healthy lifestyle attitude (= .814), and family member skin cancer experience (

= -1.296). These results indicate that females are more likely to wear sunscreen, as are those who

have healthy lifestyle attitudes. Unexpectedly, it appeared that those who have family members with

skin cancer were less likely to wear sunscreen. Refer to Table 2. Therefore we followed up this

analysis with an independent t-test examining sunscreen use with family history of the skin cancer as

the independent variable. This analysis revealed that respondents who have had a family member

with skin cancer were significantly more likely to use sunscreen. Thus, it appears that the negative

in the above regression was due to suppression effects.

44
 TABLE 2

RESULTS OF REGRESSION ANALYSIS TESTING OF SUNSCREEN ATTITUDES

Predictors b t p

Age -0.069 -0.641 ns

Gender 2.600 2.357 <.05

Skin Type -1.580 -1.562 ns

Tanning Attitude -0.176 -1.761 ns

Healthy Attitude 0.308 3.193 <.05

Knowledge 0.036 0.357 ns

Family Member/Skin Cancer -0.216 -2.225 <.05

Television Attitude 0.123 1.163 ns

Movie Attitude -0.023 -0.225 ns

R = .153; Overall F (9,99)= 51.666 ; p < .05

Behavioral Alternative Model Evaluation

Stepwise hierarchical regression analysis was used to examine the attitudes toward the

behavioral alternatives presented, as well as the role of these choices as predictors of suntanning

behavior. Demographic variables (age, sex, and skin type) were controlled for by being entered first

into the equation. Next, the behavioral alternative variables (attitudes toward suntanning, watching

television and going to the movies) were entered as a group. Other predictors entered at this time

45
included attitudes toward healthy lifestyle, attitudes toward sunscreen, skin cancer knowledge, and

family member skin cancer experiences. These variables accounted for an additional and

significant16.6% of the variance, beyond the 7.3% accounted for by the demographic variables ( F

[3,99] = 8.44, p < 05). Overall, 23.9% of the adolescents suntanning behavior variance was

accounted for and was significant ( F [10,99] = 7.93, p < .001). Examination of the beta

coefficients in the regression revealed significant s for gender ( = .218) and attitude toward

tanning ( = .429), indicating that female subjects and those with a positive attitude toward

suntanning reported a greater frequency of going outside specifically to tan. Refer to Table 3.

TABLE 3

RESULTS OF REGRESSION ANALYSIS TESTING OF THE THEORY OF ALTERNATE

BEHAVIOR AS TIMES OUTDOORS TO TAN

Predictors b t p

Age 0.081 0.790 ns

Gender . 0.218 2.019 <.05

Skin Type 0.095 0.981 ns

Tanning Attitude 0.429 4.461 <.001

Healthy Attitude -0.016 -0.170 ns

Sunscreen Attitude 0.002 0.015 ns

Knowledge -0.060 0.636 ns

Family Member/skin cancer 0.167 1.760 ns

Television Attitude -0.072 -0.715 ns

Movie Attitude -0.010 -0.100 ns

R = .239; Overall F (10,99)= 7.932 ; p < .001

46
 In addition to number of times spent tanning, we examined suntanning behavior as

defined by hours spent each time tanning using a stepwise hierarchical regression analysis.

Demographic variables (skin type, age, and gender) were controlled for by being entered first into

the equation. Next the theoretical predictors of suntanning attitudes, attitudes toward a healthy

lifestyle, attitudes toward sunscreen, skin cancer knowledge, family member skin cancer experiences,

attitudes toward watching television, and attitudes toward watching movies were entered. These

variables accounted for a significant 11.9 % ( F [ 10,99] = .72, p < .05) of hours spent suntanning

behavior variance. Refer to Table 4.

TABLE 4

RESULTS OF REGRESSION ANALYSIS TESTING OF THE THEORY OF ALTERNATE

BEHAVIOR AS HOURS OUTDOORS

Predictors b t p

Age -0.014 -0.124 ns

Gender 0.071 0.607 ns

Skin Type 0.012 0.120 ns

Tanning Attitude 0.381 3.679 <.001

Healthy Attitude 0.065 0.625 ns

Sunscreen Attitude 0.038 0.350 ns

Knowledge -0.107 -1.050 ns

Family Member/skin cancer -0.104 -1.023 ns

Television Attitude -0.075 -0.683 ns

Movie Attitude 0.004 0.043 ns

R = .119; Overall F (10,99)= .722 ; p < .05

47
 Tanning Attitudes

Because attitude toward tanning was determined to be the best predictor of suntanning

behavior, a stepwise hierarchical regression analysis was performed to examine tanning attitudes as a

dependant variable. Demographic variables were controlled for by being entered into the equation

first. Next, the predictors of attitudes toward a healthy lifestyle, sunscreen, skin cancer knowledge,

having a family member with skin cancer, watching television and going to movies were entered.

This analysis accounted for a significant 8.6% of the variance for tanning attitudes ( F [9, 99] =

53.819, p <.05). Examination of the beta coefficients in the regression revealed significant s for

skin type ( = .217) and healthy lifestyle attitude ( = .256), showing both as predictors of tanning

attitude. Refer to Table 5.

TABLE 5

RESULTS OF REGRESSION ANALYSIS TESTING OF SUNTANNING ATTITUDES

Predictors b t p

Age -0.023 -0.205 ns

Gender 2.150 1.848 ns

Skin Type 0.217 2.093 <.05

Healthy Attitude 0.256 2.499 <.05

Sunscreen Attitude -0.190 -1.710 ns

Knowledge -0.038 -0.368 ns

Family Member/Skin Cancer -0.061 -0.589 ns

Television Attitude -0.044 -0.395 ns

Movie Attitude -0.137 -1.300 ns

R = .086; Overall F (9,99)= 53.819 ; p < .05

48
 CHAPTER 4

DISCUSSION

Current research suggests that an individuals exposure to the sun during childhood and

adolescence is an important risk factor for all skin cancers. Even so, a literature review reveals that a

limited amount of research is available in which children and adolescents serve as subjects.

Therefore, the present study examined adolescents suntanning and sunscreen usage behaviors and

the role specific beliefs and attitudes have upon their behavioral choices using the Theory of

Alternative Behavior as a guiding theory. As well as examining their tanning attitudes, the

adolescents in this study were presented with the alternative choices of spending time watching

movies or watching television. As expected, suntanning behavior was significantly predicted by the

adolescents attitudes toward suntanning. Guided by the work of Jaccard (1981), attitude-scaling

techniques were used to determine relationships between self-reported suntanning behavior and the

subjects beliefs and cognitions related to suntanning.

Parent/Child Agreement

To socially validate the accuracy of the self-reported suntanning activity of the adolescents,

parents were asked to answer questions regarding the suntanning behavior of their adolescent

children. We found significant positive relationships between the responses of the adolescents and

their respective parents observations. Although significant, the relationships were weak, possibly

due to the employment of recall as a measurement tool. Furthermore, not all parents are effective

monitors of their childrens behavior; therefore parents may not have been present to observe every

49
incidence of suntanning. Though this positive finding agrees with that of Lower, Girgis, & Sanson-

Fisher (1998) who confirmed adolescent self-report to be a viable tool for research, researchers need

to be cautious about over-reliance on either recall or parents observations in future research.

Behavioral Alternatives

The behavioral alternatives of watching television and going to the movies were expected to

predict suntanning behavior and sunscreen use above and beyond the attitudes toward suntanning

and sunscreen behaviors. However, these expectations were not substantiated by the results of our

analysis. We found that while attitudes toward suntanning significantly predicted suntanning

behavior, attitudes toward alternative behavioral choices did not.

There are a number of possible explanations as to why the hypothesized relationships

between suntanning behavior and the alternatives were not significant. The initial stage of the

decision-making process involves the formation of behavioral alternatives. There has been little

actual research in which the focus has been the first stage (Jaccard, 1981), but we might expect there

to be a great deal of variance in the alternatives individuals perceive to be available at a given time.

Behavioral predictions are dependent upon the choices perceived available. Therefore, this process

of generating behavioral alternatives is central to the analysis of the attitude-behavior relationship

(Jaccard, 1980). We presented the adolescents with three alternatives for spending time on a hot,

sunny day, without asking which choices they believe might be available to them. Therefore, it is

possible that we may have selected behavioral alternatives which were not predictive of their

behavior. Because of the constantly changing choices in todays society, it may be that new, more

preferred choices have become available to this age group. Thus, this study may have been more

50
viable, had the subjects been directly asked to project behavioral choices for spending time on a hot

summer day or had different choices been given.

The second step in the decision-making process involves the evaluation of the available

behavioral choices. The format in which these choices were presented may have impacted the

results. Generally speaking, when one makes a decision, a number of available alternatives will be

considered at one time and a choice made. Once the decision is made, should a new choice become

available, individuals sometimes change their minds and choose the option presented most recently.

In the present study, it is possible the manner in which the options were presented failed to strongly

clarify that the options were to be evaluated together as a group, then rated as to how favorable the

individual felt about each. Individuals may have oversimplified the decision process by considering

each alternative individually rather than evaluating the three choices to determine a preference for

how they might spend a hot summer day. While a scenario is a useful tool, it does not replace day to

day life. Possibly a different format for questions could more effectively allow individuals to

envision what they would actually do on a hot, summer day given alternative choices. For example,

if respondents could have read the choices themselves rather than have the choices read to them

over the phone, those choices might have been easier to envision as a group of alternatives. It might

also be possible to present the alternatives through media such as videos, audio tapes or pictures.

Sunburn History and Sunscreen Use/Attitudes

It was surprising that sunburn history was not a predictor of suntanning or sunscreen

attitudes. One possibility could be the existence of the belief that sunburning is a necessary

pre-tanning event. Although participants were asked whether a base tan was a safe way to avoid

sunburns, they were not asked whether they believe a sunburn is a precursor to a tan.

51
Future research might query adolescents to determine if this belief exists.

Female adolescents in the study were more likely to wear sunscreen, but were also more

likely to spend more time in the sun. This finding also supports the premise that individuals may be

spending more time in the sun under the impression they can do so safely with sunscreen

protection. Because some forms of skin cancer result from cumulative exposures they may be

increasing their risk for these forms of skin cancer. According to the International Agency for

Research on Cancer (1992), sunscreen use may allow for increased sunlight exposure resulting in

higher amounts of UV radiation exposure.

As attitudes influence behavioral choices, having a healthy lifestyle attitude would be thought

to influence choices in suntanning behavior and sunscreen use. Therefore, it was surprising that

healthy lifestyle attitude failed to be a predictor for incidence or duration of suntanning activity.

Yet, it was a predictor of sunscreen behavior. This might seem paradoxical, unless these individuals

increase their exposure to the sun because they are wearing sunscreen. Could the general public have

a lack of understanding of the limits of protection offered by sunscreen? Certainly results of this

study appear to indicate having a healthy lifestyle attitude is not a predictor of limited suntanning

activity. Therefore, one might infer that an individual with a healthy lifestyle attitude might believe

that wearing sunscreen protects one to engage in more suntanning activity. This misbelief brings

attention to a possible flaw in educational efforts. It may be that a focus to encourage sunscreen use

indirectly creates the perception that protection from sunscreen is unlimited as long as the

protection factor is 15 or above. Among adolescents in this study reporting sunscreen use,

significantly more reported using SPF factors of 15 and above. This indicates that the public has an

understanding of the strength of sunscreen necessary for adequate protection but possibly difficulty

understanding the maximum duration for which that protection exists and the need for reapplication

52
of sunscreen periodically to maintain protection. Although those adolescents with healthy lifestyle

attitudes were significantly more likely to wear sunscreen, only four percent of the participants

reported daily sunscreen use. Therefore, this study confirms that individuals have difficulty

complying with the recommendations for daily use.

Certainly, it is possible that these individuals protect their skin through the use of hats and

clothing which covers their skin to protect themselves, as this study did not query these modes of

protection. More likely, adolescents may have optimistic bias toward skin cancer becoming a reality

in their own life. In other words, they may believe skin cancer is a potential result of unprotected

skin exposure, but believe this will happen to someone other than themselves. On the other hand,

they may perceive skin cancer to be an insignificant condition which is easily remedied. Therefore,

they may consider the benefit of having a tan (an immediate reward) to be greater than the risk of

cancer in the future. Futhermore, the inability of children and adolescents to envision themselves as

adults could be a barrier. They may perceive skin cancer to be an adult problem and perceive that

adulthood is a time very distant from the present. They may even perceive skin cancer as a condition

of the elderly. Thus, it is possible that educational material presented by peers who have

experienced skin cancer either directly or through family members could have a greater influence on

their motivation to take preventative action.

Tanning Attitudes

Interventions to shift the attitudes of children and adolescents away from unhealthy

suntanning behavior may be successfully approached through the psychological components of

these attitudes (appearance motivation, having friends that tan, and wanting to look healthy). In

regard to appearance motivation, educational interventions may assist in helping adolescents

53
understand that the darkening of skin is indicative of damaged skin. Emphasis on the more visible

and immediate effects of sun exposure such as wrinkles and accelerated aging may discourage

tanning behavior since attractiveness seems to be a common goal for most individuals. A more

effective approach may be rendered through the use of attractive, untanned role models to educate

and encourage adolescents to limit sun exposure and use sunscreen appropriately. Other research

suggests that this focus on attractiveness in which such negative effects of tanning are emphasized

may prove effective (Jones & Leary, 1994; Rossi et al., 1995).

Another possible strategy for improved success in changing perceptions would be to utilize

someone in the adolescents peer group as the facilitator of educational interventions. Adolescents

may be more willing to listen to someone with whom they feel a common bond. Furthermore,

someone in their peer group may be able to approach the subject in a more appealing way or with

more understanding of adolescents unique decision-making skills. Educational interventions could

be implemented in a variety of ways. The peer facilitator could speak to groups to educate them.

Another option would be for the peer facilitator to coordinate group sessions in which the

adolescents have the opportunity to discuss and negotiate their beliefs together. Since this is the

process used by adolescents to process their decision making, it should prove effective. Another

alternative would be the use of individual consultation by the peer facilitator of the intervention.

Gender Differences

Our study found adolescent females to be significantly more likely to be outside specifically

to tan. These findings support a growing body of evidence indicating that females may be more

likely than males to indulge in suntanning behavior (Ambrose, 1997; Leary & Jones, 1993; Robinson

et al., 1997; Vail-Smith & Felts, 1993;Wichstrm, 1994;). Even so, this finding has not been

54
confirmed by all studies. On the contrary, Johnson & Lookingbill (1984) found the male subjects

exhibited more behaviors which exposed them to the UV radiation. In another study, Reynolds et al.

(1996) found that among over 500 sixth graders on a particular weekend, males who sunbathed

spent longer intervals suntanning than did females. The discrepancy between study results may be

because of the lack of uniformity in study questions. Some studies measured frequencies of

suntanning behavior while others measured lengths of time exposed to the sun. Our study queried

both frequencies of intentional suntanning and average hours spent per exposure. This study found

females not only significantly more likely to go outdoors specifically to tan but also to spend more

hours involved in suntanning behavior.

Females were also significantly more likely to believe that their friends notice when they have

a tan and that most of their friends try to get a tan. The findings reinforce other studies which have

found that appearance motivation and having friends who think positively about suntanning to be

related to suntanning behavior. These psychological components of attitudes have been previously

discussed as an avenue of change. Peer educational interventions directed specifically toward female

appearance concerns may be successful at changing appearance motivation to tan. If females were

separated from the male adolescents for the intervention, they might feel more comfortable

discussing issues and motives related to attractiveness. Furthermore, because many females use

makeup to enhance their appearance, discussion could be included to educate individuals on the use

of makeup with sun protection factor. An effort toward the use of lighter makeup would be a subtle

advance toward making paler skin more desirable. Any of these areas could be addressed more

effectively in a female only group.

The current study also found that females reported a significantly higher number of

sunburns for the three-week period prior to the study. This is reasonable because they also reported

55
more incidents of intentional suntanning. Although incurring more sunburns, the females reported

more sunscreen use which would support the finding that individuals who use sunscreen may

increase their cumulative exposure to the sun, and thereby, increase the risk of skin cancer.

Procedural Limitations

Some procedural limitations do appear in the present study. Because this study was

administered by telephone to a parent and an adolescent, in some cases the parent may have been

present when his/her child responded to questions. If so, the adolescent subjects may have felt

pressure to give responses they thought would be acceptable to their parents. However, any such

social desirability effect is most likely minimal as the questions were designed to elicit short, single

word responses. Even so, such a possibility should be considered.

Another possible limitation concerns the season in which the data were collected. This

survey instrument was administered in the late summer, prior to the return of subjects to school;

thus the intensity of the desire for tanning might have been different than in other times of the year.

Given the positive attitude toward tanning demonstrated by their responses, these students may

have been increasing their tanning efforts because of appearance motivation. Had the survey been

administered in the spring, an increased desire to tan because of the weather change may have been

apparent. In any case, this survey instrument was designed for administration during a season in

which outdoor tanning is possible.

To allow for maximum diversity in a limited regional area, data was collected from subjects

living in a rural area in one state and from others living in a city in another state. Even so, a larger

sample that included individuals throughout the nation would be desirable to achieve a more

heterogeneous sample from which results could be more generalizable to this age group.

56
 Future Research

The results of the present study offer several prospects for future investigations using this

research design. Of primary importance in this study was the use of solid theoretical models that

have been used over time and have an accumulation of evidence to support their validity. To insure

reliability in data collection, research in this area will benefit from the continued use of reliable

theoretical models.

To better assess any differences in suntanning beliefs, attitudes, and knowledge from a

developmental perspective, a larger adolescent sample would allow statistical analysis between age

groups to show any significant differences in attitudes that might exist. Such differences, if found,

might be explained by developmental changes. This information could facilitate the effort to

provide effective interventions to meet developmental needs and create healthy attitudes.

Given the inconsistency in findings as to whether males or females receive more exposure to

UV radiation, a study based on this subject alone would provide a future research opportunity which

could shed light on previous study results. In such a study, a survey instrument could address many

different scenarios of alternative behaviors in which all alternatives are presented to both male and

female participants before they are allowed to favor an alternative.

The Alternative Behavioral Model should also prove useful in future research. Additional

research within the adolescent group might also be useful to address the need to change perceptions

regarding suntanning behavior.

57
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APPENDICES

66
 APPENDIX A

PARENT/CHILD AGREEMENT QUESTIONS

67
 APPENDIX A

PARENT/CHILD AGREEMENT QUESTIONS

Survey for Parents:

During the past 3 weeks, please tell me how often you think (name of adolescent) has gone

outside specifically to get a tan.

________Never

________Once or twice

________Three or four times

________Five or six times

________Seven or eight times

________Nine times or more

We want to know how much time you think (name of adolescent) spends lying out in the sun.

On a typical day, how many hours would your child spend lying out in the sun?

________Less than 1 hour

________1 to 2 hours

________3 to 4 hours

________5 or more hours

We want you to estimate how many sunburns (name of adolescent) had last summer (of any

kind: on his nose, face, shoulders, arms, etc.)

________Sunburn (s)

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Survey for Above Parents Child:

We are interested in your experiences with sunbathing:

1. During the past three weeks please tell me how many times you have gone outside

specifically to get a tan.

________Never
________Once or twice
________Three or four times
________Five or six times
________Seven or eight times
________Nine times or more

2. We want to know how much time you spend lying out in the sun. On a typical day, how

many hours would you spend lying out in the sun?

________Less than 1 hour

________1 to 2 hours
________3 to 4 hours
________5 or more hours

From another section of survey:

3. We want to know how often you have gotten sunburn in the last month (of any kind: on your

nose, face, shoulders, arms, etc.)

________Sunburn (s)

4. We want to know how many sunburns you had last summer (of any kind on your nose, face,

shoulders, arms, etc.)

________Sunburn (s)

69
 APPENDIX B

BEHAVIORAL ALTERNATIVE CHOICES

70
 APPENDIX B

BEHAVIORAL ALTERNATIVE CHOICES

Suppose it was a really hot summer day and you were thinking of doing something with your

friends. 1 = Very Bad

2 = Moderately Bad

3 = Neither Bad nor Good

4 = Moderately Good

5 = Very Good

Given this scenario, how good or bad would you feel about each of these:

1. Intentionally lying in the sun to get a tan. 1 2 3 4 5

2. Doing something indoors with friends (i.e. movie). 1 2 3 4 5

3. Watching television at home. 1 2 3 4 5

Suppose it was a really hot summer day and you were thinking about staying home and watching

television. How much would you agree/disagree with each of the following statements.

1 = Very Bad

2 = Moderately Bad

3 = Neither Bad nor Good

4 = Moderately Good

5 = Very Good

4. I think watching television is boring. 1 2 3 4 5

5. My friends watch a lot of television. 1 2 3 4 5

6. Sitting around watching television is a waste of time. 1 2 3 4 5

7. I like spending time with my friends when we watch television 1 2 3 4 5

together.

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Suppose it was a really hot summer day and you were thinking about going to the movies. How

much would you agree/disagree with each of the following statements?

1 = Very Bad

2 = Moderately Bad

3 = Neither Bad nor Good

4 = Moderately Good

5 = Very Good

8. I think going to the movies is boring. 1 2 3 4 5

9. My friends like going to the movies. 1 2 3 4 5

10. Going to the movies is a waste of time. 1 2 3 4 5

11. I like spending time with my friends when we go to the 1 2 3 4 5

movies together.

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 APPENDIX C

OPINIONS ABOUT TANS, LIFESTYLES, SUNBATHING, AND SUNSCREEN

73
 APPENDIX C

OPINIONS ABOUT TANS, LIFESTYLES, SUNBATHING, AND SUNSCREEN

In this section we are going to ask your opinions specific to the appearance of tans, lifestyles,

sunbathing, and sunscreen, How much would you agree/disagree with each of the following

statements? 1 = Very Bad

2 = Moderately Bad

3 = Neither Bad nor Good

4 = Moderately Good

5 = Very Good
12. I feel uncomfortable if I am pale and my friends have a tan. 1 2 3 4 5

13. How you look influences how many friends you have. 1 2 3 4 5

14. My friends notice when I have a tan. 1 2 3 4 5

15. A tan makes me look good. 1 2 3 4 5

16. Being healthy and physically fit is more important to me than most 1 2 3 4 5
people.
17. My friends play sports regularly. 1 2 3 4 5

18. My friends keep their skin healthy by using sunscreen. 1 2 3 4 5

19. I think I look healthier with a tan. 1 2 3 4 5

20. I enjoy outdoor activities. 1 2 3 4 5

21. Most of my friends try to get a tan. 1 2 3 4 5

22. My trying to get a tan at this time in my life is not a bad thing. 1 2 3 4 5

23. If I continue to go outside without sunscreen, odds are that I will 1 2 3 4 5

eventually get skin cancer.
24. I dont wear sunscreen because I dont think it really works. 1 2 3 4 5

25. I dont believe that I will get a sunburn by not using sunscreen. 1 2 3 4 5

26. I only wear sunscreen if my mother/father makes me wear it. 1 2 3 4 5

27. During the summer, I feel good about using sunscreen every day. 1 2 3 4 5

74
In this section we would like to measure how much you know about risks. How much would you

agree/disagree with each of the following statements?

28. The safe way to avoid sunburns during sun exposure is to get a base 1 2 3 4 5
tan.
29. Melanoma is the most serious type of skin cancer. 1 2 3 4 5

30. Redheads and blondes are at a greater risk for skin cancer. 1 2 3 4 5

31. It is common for people to not feel sunburned even though they are. 1 2 3 4 5

75
 APPENDIX D

FAMILY HISTORY, SUNSCREEN HABITS, SUNBURN HISTORY AND DEMOGRAPHICS

76
 APPENDIX D

FAMILY HISTORY, SUNSCREEN HABITS, SUNBURN HISTORY AND DEMOGRAPHICS

Please tell me if the following statement is true, false, or if you dont know the answer.

32. Someone is my family has/had skin cancer. T F DK

In the last section, we would like to know about you r sunscreen habits.

1. Over the summer, I use sunscreen _________ % of the time.

2. When I use sunscreen, I use a sunscreen with a number of

________4

________8
________15

________30+
________Not Sure

3. My skin

1 = always burns, never tans

2 = always burns, then tans slightly

3 = sometimes burns, always tans afterward

4 = never burns, always tans

5 = skin doesnt burn, its brown

6 = skin doesnt burn, its black

4. We want to know how often you have gotten a sunburn in the last month (of any kind: on your nose,

face, shoulders, arms etc.)

______Sunburn (s)

77
5. We want to know how many sunburns you had last summer (of any kind: on your nose, face,

shoulders, arms, etc.)

______Sunburn (s)

6. Suppose you had a typical sunburn for you. How burned would you be?

_______Not at all burned

_______Slightly burned

_______Moderately burned

_______Extremely burned

7. For your typical sunburn, how painful would it be?

_______Not at all painful

______Slightly painful

______Moderately painful
______Extremely painful

8. How difficult would it be to wear your regular clothes with your typical sunburn?
______Not at all difficult

______Slightly difficult

______Moderately painful

______Extremely painful

9. ______Gender

10. ______Age

78
 VITA

BILLIE HILL MURRAY

Personal Data: Date of Birth: June 22, 1946

Place of Birth: Bristol, Virginia
Marital Status: Married

Education: East Tennessee State University, Johnson City, Tennessee

Clinical Psychology, MA, 2001

University of Virginia at Wise, Wise, Virginia

Psychology, BS, 1995 Magna cum Laude

Professional
Experience: Wellness Educator/Counselor, 1995-2001
Eastman H.E.A.L.T.H. & Wellness, Kingsport, Tennessee
Primary Focus: Tobacco Cessation

Mental Health Practicum, Therapy /Assessment, 1997

Adolescent Unit, Woodridge Hospital, Johnson City, Tennessee

Tuition Scholarship, 1996-98

East Tennessee State University, Psychology Department

Practicum
Experiences: Bristol Regional Medical Center, 1995
Neuropsychological Assessment Testing Center, Testing
Hospice & Home Health, Counseling

Memberships &
Awards: Psi Chi, National Honor Society in Psychology
Darden Society, UVA at Wise Honor Society
Whos Who in American College Students
UVA at Wise Outstanding Research in Psychology Award

79
Memberships &
Awards (cont.)
One of two state recipients of 1993 VAEOPP Scholarships
Phi Theta Kappa, International Honor Society
American Psychological Association
Regional Youth Tobacco Prevention Team

Papers Presented
Poster presented at The Northeast Tennessee Regional Health Council
Conference on Tobacco and Health, 2001: WannaWannaQuit:
Tobacco Cessation Program.

Paper presented at Southeastern Psychological Association

Conference, 1996. Time perceptions in older humans:
Age differences in cognitive clocks?

Poster presentation for the Southeastern Psychological Association

Conference, 1995: Finding Success: Multidimensional wellness
in a population of Appalachian College Students.

80